Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for wound care for a resident with multiple wounds, as evidenced by missing documentation of wound care completion on several dates. The resident reported not always receiving daily wound care, and review of the Treatment Administration Record (TAR) for May and June showed multiple instances where wound care was not documented as completed for both left and right wounds, including specific treatments such as cleansing, application of santyl, collagen, medi-honey, and dressing changes. There was also no documentation indicating that the resident refused care on these dates. During an interview, the Director of Nursing confirmed the findings and acknowledged that the resident occasionally refused care, but the medical record and TAR did not reflect refusals or provide explanations for missed treatments. The lack of documentation and failure to follow physician's orders for wound care constituted a deficiency in meeting professional standards of quality for the resident's pressure ulcers.